Although it is possible to perform innovative surgery treatment of various maladies affecting the human body, in some cases, it is not always reasonable or practical to do so. A recent example of this view is a current recommendation to perform bilateral surgical intervention for symptomatic carpal tunnel syndrome. Carpal tunnel syndrome is the most common upper-limb compressive neuropathy, as recently reaffirmed in this study by Osei and colleagues comparing patients undergoing simultaneous bilateral carpal tunnel release and those undergoing unilateral carpal tunnel release. Many presentations of carpal tunnel syndrome, especially in patients with diabetes, hypothyroidism, and inflammatory arthritis, have bilateral involvement. Since it was first described by Phalen et al. in 1950, there have been several different surgical techniques described for carpal tunnel release. The classical incision begins in the palm and crosses the wrist flexion crease. This extended incision is recommended when there has been a distal radial fracture or when synovectomy for inflammatory arthritis or other tendinopathies is considered. Small palmar incisions (2-cm length) and even mini-incisions and endoscopic procedures can be applied to divide the transverse carpal ligament, but perhaps with less certainty as to the specific area of ligament division, especially with respect to the ulnar border of the carpal ligament adjacent to the hook of the hamate. The location of the incision (more ulnar than radial) may be important to avoid a healing carpal ligament (scar) directly adjacent to the median nerve. Following surgery, there are also different opinions as to the need to immobilize the wrist to ensure ligament healing, prevent soft-tissue interposition, and provide normal tendon gliding through the palmar pulley (transverse carpal ligament). Wrist immobilization may also be of benefit to limit overuse by the patient in performing activities of daily living. Immobilization of the wrist for two to three weeks is considered a reasonable approach to preserve ligament healing and to prevent the complication of pillar pain (a painful palmar scar related to delayed healing)

Osei and colleagues compared simultaneous bilateral carpal tunnel release with unilateral carpal tunnel release in consecutive patients with carpal tunnel syndrome. Outcomes were appropriately studied by patient functional studies (QuickDASH, a shortened version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire, and the Boston Carpal Tunnel Questionnaire). The study was performed in a dual-cohort, non-randomized, prospective fashion. The wrist was not immobilized. The time for evaluation was early at the first postoperative visit (mean, ten days) and a second evaluation was performed at the second postoperative visit (mean, thirty days). The patients were asked to judge their ability to perform activities of daily living, including opening a jar, carrying groceries, cooking, doing household chores, and driving after undergoing either unilateral or bilateral carpal tunnel release surgery. Further, they performed their own personal hygiene usually with a home assistant and with the assistance of extra-large latex-free gloves. It was not clear if the gloves were worn all of the time or only when exposed to conditions of potential contamination (washing dishes or personal hygiene). Although I personally have performed bilateral carpal tunnel release in special circumstances in patients who need minimal downtime related to their work (surgeons, dentists, computer-entry personnel, and other white-collar workers), it has never been recommended for blue-collar workers, Workers’ Compensation cases, the elderly, or patients with systemic disease associated with carpal tunnel syndrome. An evidence-based approach to these issues of appropriate conservative or surgical treatment of carpal tunnel syndrome with clear answers to the question of diagnosis, treatment, and outcomes is still elusive. Osei and colleagues correctly make a case for their study, suggesting that guideline decision-making is lacking in the decision to perform bilateral carpal tunnel release. That decision-making guidelines are lacking is likely true because, in a questionnaire to members of the American Society for Surgery of the Hand, the majority of hand surgeons did not believe that bilateral surgical treatment is commonly indicated. One benefit of this comparative study is that it gives both surgeons and patients an idea of what to expect after bilateral carpal tunnel surgery and, specifically, what is needed in their ability to perform activities of daily living.